Washington – In what is not really a joke, severely-injured veterans sometimes quip, “I need a case manager to manage my case managers.”

In a case of good intentions gone awry, efforts to smooth wounded warriors’ transition from DoD to VA health-care services has created a confusing web of services. Now, the Government Accounting Office is investigating those services and has foundserious problems in terms of compatibility and communication.

In 2007, in response to reports of veterans becoming lost in the transfer between DoD and VA health-care systems, Congress called for the creation of a Federal Recovery Coordinator Program (FRCP). The intention was for federal recovery coordinators (FRCs) to be a single point of contact for severely injured veterans as they move from system to system, managing their care and keeping them and their family informed and oriented in the sometimes confusing care systems.

Four years later, the FRCP exists as a program run solely out of VA and finds itself in a landscape filled with military service programs providing similar services, most notably the DoD Recovery Coordination Program. The result is that these various programs are sometimes in competition, providing overlapping services and conflicting recovery plans for veterans, with nothing resembling the single point of contact envisioned by those original advocates for the FRCP. That program alone has grown to include 22 FRCs nationwide serving 734 severely injured veterans.

Competing Case Managers

Ironically, the goal was to streamline and simplify when the Dole-Shalala Commission—an independent federal committee tasked with investigating the state of care for returning servicemembers, especially at Walter Reed Army Medical Center—recommended the creation of the FRCP.

Since then, other programs with the same goal have been created. DoD’s Recovery Coordination Program, currently staffed by 146 recovery care coordinators (RCCs), was created in the FY2008 Defense Authorization Act. There also are wounded warrior programs within specific military services. Veterans can find themselves with an Army care coordinator, as well as an RCC and possibly an FRC, especially if they are unlikely to return to service. The GAO investigation has identified some significant problems in how these programs function together. In one instance, a multiple amputee who had both an RCC and FRC was advised by his FRC to separate from the military in order to receive needed services from VA. The RCC, on the other hand, set a goal for the veteran to remain onactive duty.

“Coordination of these programs is paramount to minimize overlap, minimize information and prevent confusion among enrollees and their families,” Randall Williamson, GAO director of health care, told the House Veterans Subcommittee on Health at a hearing last month. “We’ve found that considerable overlap does occur, along with conflicting recovery plans on occasion. This adds to confusion among servicemembers and their families and is not in the best interest of the recovering servicemember.”

When to Intervene

Part of this problem is a disagreement between DoD and VA as to when the FRC should become involved in injured troops’ care. The view of many DoD officials is that FRCs do not need to be involved until it is apparent that the servicemember will likely be discharged from military service. However, FRCs contend that they should be involved long before that, to help build trust with their clients and their families throughout the continuum of care.

“A recurring theme as we’ve talked with military staff in other programs was, ‘We can take care of our own while they’re recovering on active duty. We don’t need VA involved’,” Williamson said.

VA and DoD officials testifying before the subcommittee demonstrated this conflicting attitude as to the role of the FRCP. “Many in DoD believe that FRC is a redundant program, probably because DoD’s Recovery Coordination Program was modeled directly on FRCP, including the design for the comprehensive recovery plan,” explained FRCP Director Karen Guice, MD. “Others in [wounded warrior programs] say that FRCP should only provide support for veterans because they’re not in the military’s chain of services command.”

“FRCP is designed to be that single point of contact,” Guice said. “Our clients tell us that FRCP works best when they intervene early in recovery and prior to the first transition.”

In RCC Director Robert Carrington’s opinion, however, the FRC should be the point of contact only when it becomes apparent that the servicemember will be transferring to VA. “FRCs and RCCs serve similar functions, but in different categories,” he said. ‘The FRC’s focus is for those unlikely to return to duty or be medically separated.”

Cultural Barricades

It is possible, officials and overseers agreed, that there was a fatal flaw in the original design of the FRCP. Instead of being a truly joint program — both in purpose and in administration — it was placed almost solely under VA. Thus, instead of straddling the departments, the program finds itself hobbled by the cultural differences between VA and the military services.

“The culture problem is probably the No. 1 barrier,” Williamson told legislators. “Breaking down the cultural differences between VA and DoD so they can cooperate is probably the single most important thing we need to do.”

The original Dole-Shalala Commission report that pushed for the FRCP recommended that it be placed under the Public Health Service, in order to prevent the VA or DoD from having total or unequal ownership of the program. For various logistical and budgetary reasons, Congress did not follow that recommendation.

Rep. Ann Marie Buerkle (R-NY), who chairs the subcommittee, admitted that, if she could start from scratch with the FRCP, she would find a way to put it somewhere between VA and DoD, with joint ownership from both departments and joint funding. “You need to have that cooperation and capability of working side-by-side, so you’re working the issues every day and working the challenges every day, and you have a uniting place where those dialogues can occur,” Buerkle said. “Having it isolated in either department won’t work.”Carrington said he is willing to have a joint program, but his description of a joint program is putting the FRCs under military command. “Right now, there are two separate programs, and I think our services would tell you, in short, ‘Give us those FRCs, let us include them on our team, let us be responsible for them, let us put them under our leadership, let them focus on accomplishing our mission, and we’ll probably see more success.’ ”

However the cultural differences are addressed, Williamson says he believes it is time to reevaluate the entire, complicated system of wounded warrior programs that have developed over the last four years. “There are now at least 10 wounded-warrior programs. It’s time to step back with an impartial eye and look at this,” Williamson said. “And with the culture differences between VA and DoD, I’m not sure we’re going to get that kind of impartiality within the agencies.”

While GAO has completed evaluations of the FRCP, it is still in the process of evaluating the various military wounded-warrior programs. Williamson said he thinks the completed investigations will have some recommendations that concern both VA and DoD, adding, “I hope [DoD] has heard the need for all wounded-warrior programs to work together and to play well in the same sandbox.”